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Learning in Stride: Evidence and Experience

on things that are not, and perhaps cannot be, taught

By Stephanie Tillman, CNM, MSN

I began outlining this post on the back of an Audre Lorde essay, sent to me by a friend who shared it with other first-year clinicians struggling to make the day-to-day happen. In "The Transformation of Silence into Language and Action," excerpted from Sister Outsider, Lorde writes of the time after her breast cancer diagnosis and what she describes as her 'living':

"...for every real word spoken, for every attempt I had ever made to speak those truths for which I am still seeking, I had made contact with other women while we examined the words to fit a world in which we all believed, bridging our differences. And it was the concern and caring of all those women which gave me strength and enabled me to scrutinize the essentials of my living" (p 41).

For those continuing to study for boards, for those working through the first year of practice, and for seasoned midwives, I share this quote as a reminder that the words we speak in conversations with women have the power to break a silence, to transform our own work and a woman's life into something different, and often to catalyze action. Each opportunity to turn "silence into language" should be approached with great care, studied and carefully examined afterward, and checked for future approaches. Outside the academy it comes down to our personal volition to do this: to revisit our language, consider it carefully, and update it as needed.

Despite all the instruction about breast cancer screening guidelines, follow-up, and management, I was unprepared to read a faxed biopsy-result describing “infiltrating ductal carcinoma,” and to inform a woman of her breast cancer diagnosis. To sit and cry with her and her partner, to feel speechless and unsure about whether the silence needed to be filled or let be. I am still not always prepared to receive updates from her team about her care, her consultations and post-op reports, each one indicating further progression of her disease and transformative surgeries. Each piece of language chosen during that first moment may be remembered vividly, and could dramatically transform a woman’s actions and life. You must break a silence that cannot be restored.

For all the instruction about sexually transmitted infections, an asymptomatic diagnosis of chlamydia will drastically change a woman's day, her communication with her partner/s, and the movements she makes in her current and future relationships. You must break a silence that she did not know was even there.

For all the instruction I received about depression, a woman opening up and breaking down over her daily struggle to get control of her emotions is overwhelming. It has been for me, anyway. Whether a new patient, a postpartum patient seen prenatally, or a government-covered annual exam to screen for cancer, such an admission is someone finding the confidence to break their own silence, and seek help.

I list these examples because the most I have learned about myself as a midwife has been in these moments, when the facts are irrelevant and holistic care is everything. Once graduated, our silence, our language, our action as a midwife, defines our work, our role, and our profession. There is no teaching-to-the-Boards that goes along with this work. There is often no evidence basis to this work.

But, what of the evidence? Though much of what we do is evidence-based, I learned quickly that evidence does not necessarily translate into actions or protocols. Through rotations at clinical sites as a student, I witnessed doubt of the "latest evidence," belief in learned experience, and emphasis on caring. I remember, vividly, questioning various practices and discussing the most recent evidence I had learned in school, holding it up like a shining trophy to my preceptors. And each midwife had her own response, ranging from true interest, to patient encouragement toward caution around the latest and greatest ("Now, was that a meta-analysis?"), to pointing out her own trophy: evidence & experience, rightfully shining bigger and brighter than my own.

I recognized the wisdom in these circumstances, but I still judged their practices, knowing that they were not what I had been taught and that perhaps I would do differently some day. I still do that with the midwives in my own practice, to some extent, but I have come to believe in midwifery and midwives. I follow my brain and heart in my work. I am realizing the best midwives tried to teach me that all along. Do I now practice evidence-based? I practice that evidence which is most important; the rest is, and must, be flexible to the woman and the situation.

Start and continue to ask yourself these questions: What kind of a midwife will you be? What will cause you to change the practices you learned in school? New, compelling studies? Women's feedback? Experience? What caused you to create your practices in the first place, and through what "cultural blinder," as written by Henci Goer and Amy Romano in Optimal Care in Childbirth (p 17), were those evidence-based practices founded? And what about the grey areas of obstetrical care, where the evidence is lacking but standard practice prevails? How will you find strength from women and fellow midwives to enable you “to scrutinize the essentials” of your practice, and allow that to transform your ways of silence and language and action?

Stephanie Tillman is a recently-graduated Nurse-Midwife now practicing full-scope midwifery in the urban United States, at a Federally Qualified Health Center (FQHC) and as a member of the National Health Service Corps (NHSC). With a background in global health and experience in international clinical care, the impact of public health and the broader profession of midwifery are present in all her thoughts and works. Stephanie's blog, Feminist Midwife, discusses issues related to women, health, and care. Find out more at and follow her on Twitter at @feministmidwife.
Posted By Barbra Elenbaas | 2/14/2013 10:44:27 AM



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